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Exchange Market Role

The Health Care Reform Implementation Council thanks you for your continued interest and participation in the implementation of the Affordable Care Act in Illinois. As we begin 2013 and the 98th session of the Illinois General Assembly it is important for us to seek your advice on ways we can assure access to affordable health care through the health insurance exchange that will begin open enrollment in October.

The Council is identifying functions for a state-based Health Insurance Exchange that will help assure premiums are affordable. Georgetown University Health Policy Institute recently released a report on the components of a state insurance exchange that contribute to lower premiums. Based on the Georgetown University report, we’ve identified several examples of efforts an exchange can pursue to offer high quality, affordable health insurance to individuals and small groups. The report that can be found here.

We would like to know how you would prioritize these functions to assure a state-based exchange offers affordable health coverage for consumers:

A.Additional certification criteria: Authority to add to the federally required standards for plan certification with criteria that reflect the state’s goals for such things as population health, plan quality, access to providers, delivery system reform and transparency. For example, the exchange could require participating plans to engage in specific efforts to promote interoperable health IT in clinical settings.

B.Selective contracting and negotiation on price/quality: Certified plans would be allowed to bid for exchange business and plans would be chosen based on their bids through a procurement process or other type of negotiation between the exchange and carriers.

C. Limiting the number of products: The authority to limit the number of products a carrier can sell on the exchange. Research has shown that too much choice can be confusing to consumers.

D. Setting standards for cost-sharing: Ability to limit the number of available benefit designs and standardizing deductibles and co-payments for certain clinical services. Standardizing cost-sharing can help prevent selection bias in health plans.

E. Piloting new delivery system and reimbursement strategies: Aligning incentives among purchasers and payers to encourage long-term, systemic changes in the way health care is paid for and delivered. For example, exchanges might encourage plans to implement new reimbursement strategies and value-oriented benefit designs to improve health outcomes.

F. Aligning with other state purchasers (i.e., Medicaid, state employee plans): Allowing the exchange to coordinate purchasing initiatives with other state purchasers so that all are sending consistent signals to carriers and providers, such as encouraging medical homes. Additionally, aligning public medical programs with the exchange (such as the County Cares program in Cook County) will encourage continuity of care for those whose care shifts to or from Medicaid and premium subsidy.

G. Recruiting and assisting new market entrants: Allowing the exchange to encourage competition through recruiting new carriers to the state or assisting home-grown regional carriers or Medicaid plans to meet requirements for offering products through the exchange.

H. Use of web-based decision tools to drive value-oriented decisions by consumers: The application of a robust plan finding tool that includes strategic choice architecture and allows consumers to narrow down choices based on provider or other preferences.

I. Rate Review: Authority for the Department of Insurance to approve or deny rate increases for plans sold on the exchange. Under the ACA, each state is required to review but does not have the authority to deny premium increases unless authorized by state law.